Injury Report Template: OSHA Fields, Details & Signatures

Injury Report Template

[Organization / Employer / School / Program Name]

[Address]

[City, State/Province, ZIP/Postal Code]

Phone: [Phone Number]

Email: [Email Address]

1. Injured Person Information

Full Name: [First, Middle, Last]

Date of Birth: [MM/DD/YYYY]

Age: [Age]

Gender: [Gender]

Role (check or describe):

• Employee

• Student / Child

• Athlete / Participant

• Visitor / Customer

• Contractor / Vendor

• Other: [Describe]

Home Address:

[Street Address]

[City, State/Province, ZIP/Postal Code]

Phone Number: [Phone Number]

Email Address: [Email Address]

2. Incident Date, Time, and Location

Incident Date: [MM/DD/YYYY]

Incident Time: [HH:MM a.m./p.m.]

Location of Incident (room, area, field, worksite, street, etc.): [Location]

Type of Setting (check one):

• Workplace

• School / Childcare

• Sports / Recreation

• Public place / Business

• Roadway / Vehicle / DUI-Related

• Home / Residential

• Other: [Describe]

3. Activity at the Time of Injury

Describe what the injured person was doing at the time of the incident (be specific):

[Example: “Lifting boxes onto a shelf,” “Running during PE class,” “Walking through hallway,” “Driving northbound on [Street],” “Playing in a soccer match.”]

Was this a normal / expected activity for this setting?

• Yes

• No – explain: [Brief explanation]

4. Description of Incident

Provide a clear, factual description of how the incident occurred. Avoid opinions or assigning blame; focus on what happened.

Description of Incident:

[Free-text narrative. Suggested points to cover:]

• What was happening immediately before the incident.

• How the injury occurred (slip, trip, fall, struck by object, collision, sudden movement, etc.).

• Surfaces, equipment, vehicles, or substances involved (wet floor, steps, machinery, another vehicle, ball, etc.).

• How the injured person landed, was struck, twisted, or otherwise hurt.

5. Injury Details

Body Part(s) Injured (check or describe):

• Head / Scalp

• Face / Eye / Nose / Mouth

• Neck

• Shoulder / Arm / Elbow / Wrist / Hand

• Chest / Ribs

• Back / Spine

• Hip / Thigh

• Knee / Lower Leg

• Ankle / Foot / Toes

• Multiple areas

• Other: [Describe]

Side of Body: [Left / Right / Both / Center / Unknown]

Type of Injury (check all that apply):

• Bruise / Contusion

• Cut / Laceration / Scratch

• Abrasion / Graze

• Sprain / Strain

• Suspected Fracture / Dislocation

• Burn (thermal / chemical / electrical)

• Bite / Sting

• Concussion / Head Impact (suspected)

• Other: [Describe]

Visible Signs of Injury:

[Example: redness, swelling, bleeding, deformity, limited movement, discoloration.]

6. Symptoms and Pain

Injured Person’s Reported Symptoms (use their own words where possible):

[Free-text, e.g., “sharp pain in right ankle when walking,” “headache,” “dizziness,” “nausea,” “numbness in fingers.”]

Pain Level (0–10 scale; 0 = no pain, 10 = worst pain imaginable):

Reported Pain Score: [0–10]

Other Observed Signs (check or describe):

• Dizziness / unsteady gait

• Confusion / disorientation

• Difficulty speaking or responding

• Shortness of breath

• Pale / sweaty / clammy skin

• Loss of consciousness (approximate duration: [Time])

• Vomiting

• Other: [Describe]

7. Immediate Response and Treatment

Did the injured person stop activity immediately?

Person(s) Providing First Aid or Initial Response:

Name(s) and Role(s): [List]

Care Provided On-Site (check all that apply):

• Area cleaned

• Bandage / dressing applied

• Ice pack / cold compress

• Pressure applied to control bleeding

• Immobilization (splint, sling, brace)

• Elevation of injured area

• Rest and observation in designated area

• CPR or emergency life support (briefly describe)

• Other: [Describe]

Was 911 / Emergency Medical Services called?

• Yes

• No

If Yes:

• Time Called: [HH:MM a.m./p.m.]

• Responding Agency: [Name]

• Transported to Medical Facility? [Yes / No]

• Facility Name: [Hospital / Clinic Name]

8. Medical Evaluation and Work/School Status

Did the injured person receive or seek medical evaluation after leaving the scene?

• Yes

• No

• Unknown at time of report

If Yes, specify:

• Facility / Provider Name: [Name]

• Type of Facility: [ER / Urgent Care / Clinic / Personal Doctor / Other]

• Date of Visit: [MM/DD/YYYY]

Has a doctor or medical provider given written work, school, or activity restrictions?

• Yes – describe: [e.g., “No sports for 2 weeks,” “No lifting over 10 lbs,” “Seated work only.”]

• No

• Unknown

Work / School Status Immediately After Incident:

• Returned to normal duties / activities

• Returned with temporary restrictions

• Sent home

• Transported for medical care

• Other: [Describe]

9. Witness Information

Were there any witnesses to the incident?

• Yes

• No

• Unknown

Witness 1:

Full Name: [Name]

Role (employee, student, customer, etc.): [Role]

Phone / Email (if needed): [Contact]

Brief Witness Statement (summary of what was seen or heard):

[Free-text summary]

Witness 2:

Full Name: [Name]

Role: [Role]

Phone / Email: [Contact]

Brief Witness Statement:

[Free-text summary]

[Add additional witness sections as needed.]

10. Notifications

Person(s) Notified (check and complete):

• Parent / Guardian

• Supervisor / Manager

• HR / Safety Department

• School / Program Administrator

• Property Owner / Landlord

• Other: [Describe]

Details:

Name of Person Notified: [Name]

Role / Relationship: [Role]

Method of Notification: [In person / Phone / Voicemail / Email / Other]

Date and Time of Notification: [MM/DD/YYYY – HH:MM a.m./p.m.]

Summary of What Was Communicated:

[Free-text summary]

11. Follow-Up and Corrective Actions

Planned or Completed Follow-Up Actions (check or describe):

• Monitor injured person’s condition at subsequent visits / shifts.

• Request medical documentation or work status note.

• Inspect area, equipment, or conditions involved.

• Repair, clean, or modify equipment or environment.

• Provide refresher training or safety reminder.

• Update internal policies or procedures.

• Other: [Describe]

Person Responsible for Follow-Up: [Name and Title]

Target Date for Completion: [MM/DD/YYYY]

12. Signatures

Reporting Person

I certify that this Injury Report reflects my understanding of the incident and information available at the time of completion.

Name: [Reporting Person Full Name]

Position / Role: [Title / Relationship]

Signature: ___________________________

Date: [MM/DD/YYYY]

Supervisor / Administrator Review (if applicable)

I have reviewed this report and will ensure that appropriate follow-up and safety actions are considered and, where approved, implemented.

Name: [Supervisor / Administrator Name]

Title: [Title]

Injured Person / Parent / Guardian Acknowledgment (if required)

I acknowledge that I have been informed of the contents of this Injury Report. This acknowledgment does not indicate agreement with any conclusions and is not a waiver of any rights.

Name: [Injured Person / Parent / Guardian]

Signature: ___________________________

Date: [MM/DD/YYYY]

13. Additional Notes or Attachments

Additional Notes:

[Free-text area for any other relevant information not covered above.]

Attachments (check if included):

• Photos of injury or scene

• Separate incident / accident investigation report

• Medical note or discharge summary

• Internal safety or HR forms

• Other: [Describe]